Abstract
Chinese Taoist cognitive therapy (CTCT) is a culture-oriented cognitive psychological therapy developed by Chinese psychiatrists. In this paper, we reviewed the published studies in the past years that investigated possible effects of CTCT in the treatment of common psychiatric symptoms and disorders. In summary, the current literature provided relatively ample evidence that CTCT can help to reduce depressive symptoms in both clinical and non-clinical Chinese populations. A relatively large number of studies also supported the opinion that CTCT can help to relieve anxiety in participants with anxiety disorders. Some other studies also suggested that insomnia, cognitive impairment, and alcohol dependence can be treated by CTCT; however, such conclusions might be considered as exploratory before they are repeated. Further studies can be conducted in larger sample sizes to provide more solid evidence, and in participants with other psychiatric symptoms/disorders that have not been investigated.
Introduction
Chinese Taoist Cognitive Therapy (CTCT) is a culture-oriented cognitive psychological therapy developed by Chinese psychiatrists, Dr. Desen Yang and his colleagues in 1988 [1]. It is a systematic, indigenous, culturally-grounded cognitive therapy developed based on “Taoism” (or “Daoism”), an ancient Chinese philosophy and religion that has significant influences on traditional Chinese culture [2,3]. Since its foundation, the CTCT has been used by many psychiatrists from China and other countries, and has been proven to be therapeutically effective for a number of common psychiatric symptoms and disorders, such as anxiety and depression [3-11].
The entire process of CTCT consists of five stages, which are called “ABCDE” by some Chinese psychiatrists. In short, the first three stages are estimating the patient’s “actual stress” (“A”), “belief System” (“B”), and “conflict and coping styles” (“C”), respectively, for a comprehensive understanding of the patient’s psychological conditions for the following therapy. The fourth stage is called “doctrines direction” (“D”), which is the core stage of CTCT aiming to lead to a cognitive restructuring. After that, the final stage is the “effect evaluation” (“E”) where some scales may be used for psychological evaluations, and the plans for the following treatments can be scheduled. More detailed information about such a process can be found in some previous publications [1,3].
Compared to some other forms of cognitive therapy originating from Western cultures, the CTCT has a relatively short history and is still in development; the evidence for its effects on many psychiatric symptoms and disorders remains unclear and debating. To fill such a gap, Ding and colleagues wrote a systematic review of published studies to assess the possible effects of CTCT for reducing symptoms of anxiety and depression in Chinese adults. They concluded that CTCT can help to reduce depressive symptoms, including both clinical and non-clinical depressive symptoms, while the effectiveness of CTCT for anxiety symptoms is debatable. This meaningful study is very helpful for guiding future studies on CTCT, as well as the usage of CTCT in clinical practice [3].
Nowadays, however, the above-mentioned review by Ding et al. is limited in several respects [3]. First, this review was published in 2020, and many new studies on CTCT have been conducted and published since then. It is unclear whether the new findings in recent years would lead to different conclusions compared to the prior results. Second, the review by Ding et al. only assessed the potential effects of CTCT on depression and anxiety. Nevertheless, a review of literature related to the effects of CTCT on other common psychiatric symptoms and disorders, such as insomnia, cognitive impairments, as well as substance and non-substance addictions, is still lacking. Therefore, an updated review is needed to summarize the newer studies, as well as those studies on the effects of CTCT for any common psychiatric symptoms and disorders other than anxiety/depression, and this paper aims to fill such gaps.
Effects of CTCT on Depression
The previous review by Ding et al. has concluded that CTCT can significantly reduce depressive symptoms in Chinese adults, not only in patients with chronic diseases but also in the non-clinical populations [3]. Such conclusions are supported by multiple published studies that reported consistent trends. For example, Huang et al. provided preliminary evidence that CTCT is effective in the treatment of major depressive disorder (MDD) in a study enrolling 35 Chinese young patients (16 males and 19 females; 29.5 years old on average) [5]. After that, Yang at al. and Wen et al. both reported that CTCT is effective for treating late-life depression, which is typically defined as MDD occurring in people over the age of 50 [8,12,&13]. Another randomized controlled trial by Zhang et al. also reported that combining the CTCT and drug therapy would be more effective in reducing depressive symptoms than only-drug therapy in patients with MDD [9].
In 2017, Huang et al. investigated the role of CTCT in the treatment of post-stroke depression by performing a comparative study enrolling a total of 150 patients with stroke [6]. Their results suggest that compared with the control group, the patients’ depressive symptoms estimated by the Hamilton Depression Scale (HAMD) scores can be significantly relieved by receiving CTCT. Huang et al. also investigated the possible effects of CTCT on depressive symptoms in 150 non-clinical individuals enrolled from Changsha city, China [14]. Similar to the study conducted in clinical populations, they found that CTCT can significantly reduce the depressive symptoms measured by the HAMD scores in non-clinical populations, with both short-term (4-8 weeks) and long-term (12 months) effects. Several other studies have also reported that CTCT is useful in reducing depression in patients with multiple chronic psychiatric/physical diseases, such as post-stroke depression, hypertension, and diabetes mellitus [7,15&16].
In summary, the above earlier studies have provided relatively ample evidence that CTCT is effective in reducing depression in patients with MDD, patients with chronic physical diseases suffering from depressive symptoms, as well as non-clinical populations. Since 2020, several newer studies have also reported similar results, and further supported such conclusions. For example, a recent study in Hong Kong including 29 participants aged 25-78 years suggested that depression, anxiety, and stress symptoms can be reduced after a 4-week intervention of CTCT [17]. In addition, some recent studies proved that Taoist values can influence depression in college students through the mediating roles of locus of control and positive coping styles [18]. Although not applying CTCT directly, such results can provide empirical support for using CTCT in the treatment of depression.
Effects of CTCT on Anxiety
In the early 2000s, Zhang et al. has explored the role of CTCT in the treatment of anxiety disorder in a series of studies enrolling 143 patients [10,11]. They found that CTCT is effective for reducing anxiety symptoms, and CTCT takes effect more slowly but has better long-term effects when compared to conventional drug therapy. Zhang et al. then concluded that the best way to treat anxiety disorder might be to combine drug therapy and CTCT.
In the 2010s, some other studies have reported that CTCT can significantly reduce anxiety symptoms in both the clinical and non-clinical populations. In patients with stroke, it was found that CTCT can significantly reduce the severity of anxiety symptoms as estimated by the Hamilton Anxiety Scale (HAMA) scores [6]. In non-clinical populations without a history of severe physical/mental diseases, it was also found that CTCT can significantly relieve anxiety assessed using the HAMA [14]. Besides, another case report described the successful application of CTCT to a 32-year-old Chinese American immigrant woman with generalized anxiety disorder [4].
By 2020, the number of studies focusing on the effects of CTCT on anxiety disorders was relatively small (and mostly with relatively small sample sizes); Ding et al. thus proposed that the related results may be biased and should be considered exploratory in their review published in 2020 [3]. Nevertheless, it is noteworthy that some new studies have been performed after 2020, and new evidence has been reported. For instance, Chang et al. tried the application of CTCT in a sample of Chinese American immigrants with generalized anxiety disorder and found that CTCT can lead to significant improvements in anxiety/worry, although it was thought that such findings should be replicated in a randomized controlled trial [19]. The recent study in Hong Kong reported by Yin also suggested that anxiety symptoms can be reduced after a 4-week intervention of CTCT; a total of 29 participants aged 25-78 from Hong Kong were included in such a study. Furthermore, some other studies reported that anxiety levels in college students can be reduced by Tai Chi Chuan originating from Taoist philosophy, which could also partly support the effects of Taoism/CTCT in reducing anxiety [17,20]. Taken together, these studies may further support the opinion that CTCT can be effective in reducing anxiety in participants with Chinese cultural backgrounds.
Effects of CTCT on Other Psychiatric Symptoms and Disorders
Yang et al. found that CTCT is potentially effective in the treatment of insomnia by performing a randomized controlled trial [21]. In their study, a total of 42 patients with insomnia were recruited and randomly divided into the test group (n = 21) and control group (n = 21). Patients in the test group received both CTCT and drug therapy, while those in the control group received only drug therapy. The results indicated that compared to the control group, patients in the test group had significantly better sleep quality after the 8-week therapy.
CTCT has also been suggested to be potentially effective in treating addiction, such as alcohol dependence. Zhou et al. performed a randomized controlled trial in which patients were divided into the control group and the test group [22]. In the control group, participants received conventional treatments for alcohol dependence, while those participants in the test group were treated by conventional treatments plus CTCT. It was reported that after one year, the alcohol abstinence rate was significantly higher in the test group (53.13%) than in the control group (15.40%). Furthermore, some factors such as the course of illness, brain injury, and family history of alcohol abuse were reported to be associated with the effects of CTCT in the treatment of alcohol dependence.
One study by Wang et al. suggested that CTCT might be effective in preventing cognitive impairments following cerebral infarction [23]. Such a conclusion was drawn by performing an 8-week follow-up study including 62 patients with a history of cerebral infarction, in which patients’ cognitive functions were measured using the Mini-Mental State Examination (MMSE). Another study by Lu et al., interestingly, reported that cognitive function can be improved through CTCT in patients with residual schizophrenia [24].
Discussion
In this study, we reviewed the published studies in the past years that investigated the possible effects of CTCT in the treatment of common psychiatric symptoms and disorders. The most frequently reported conclusion in previous studies is that CTCT can help to reduce depressive symptoms, including both the severity of depression in patients diagnosed with MDD and other diseases, as well as subclinical depressive symptoms in the general population. Ample evidence has been provided to support such a conclusion by many studies, including some published in 2000s/2010s and also several recently published ones [5-8,12,14,16&17]. A relatively large number of studies also suggested that CTCT can help to reduce anxiety symptoms in those Chinese participants diagnosed with anxiety disorders. Such a conclusion was suggested by some earlier studies in the 2000s/2010s, and further supported by some newer studies conducted after 2020 [4,10,11,17&19].
Besides depression and anxiety, there are also several other common psychiatric symptoms and disorders that can be treated by CTCT as reported by some published studies. These psychiatric symptoms and disorders include, for example, insomnia, cognitive impairments, and alcohol dependence [21-23]. These studies provided important evidence for the potential clinical applications of CTCT in a wider range. Nevertheless, it is noteworthy that the number of studies focusing on these symptoms and disorders is still small, and the conclusions might be considered exploratory before they are confirmed in more studies.
There are some limitations and potential future research directions to be noted. Firstly, we notice that in most of the published studies focusing on the effects of CTCT in clinical practices, the sample sizes are still relatively small (e.g., < 100 participants per group). Future studies performed in larger samples might be needed to provide more solid conclusions. Second, some psychiatric symptoms and disorders have not been investigated in the current literature and may be explored in future research. For instance, while it has been reported that CTCT can treat alcohol dependence, whether CTCT would be effective in the treatment of other substance and non-substance addictions, can be a meaningful question to explore [22,25&26]. Third, the possible biological mechanisms underlying the effects of CTCT remain unknown and might be explored. For example, it is well known that depression/anxiety is associated with brain dysfunctions as revealed by functional neuroimaging methods; whether CTCT would lead to changes in certain brain circuits during the treatments of depression/anxiety can be another interesting question [13,27&28].
Conclusion
We reviewed the published studies in past years that investigated possible effects of CTCT in the treatment of common psychiatric symptoms and disorders. The current literature provided relatively ample evidence that CTCT can help to reduce depressive symptoms in both clinical and non-clinical Chinese populations. A relatively large number of studies also supported the opinion that CTCT can help to relieve anxiety in participants with anxiety disorders. Some other studies also suggested that insomnia, cognitive impairment, and alcohol dependence can be treated by CTCT; however, such conclusions might be considered as exploratory before they are repeated. Further studies can be conducted in larger sample sizes to provide more solid evidence, and in participants with other psychiatric symptoms/disorders that have not been investigated.
